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Fernandez-Sarmiento J, Perez MC, Bustos JD, Acevedo L, Sarta-Mantilla M, Guijarro J, Santacruz C, Pardo DF, Castro D, Rosero YV, Mulett H. Association between mechanical ventilation parameters and mortality in children with respiratory failure on ECMO: a systematic review and meta-analysis. Front Pediatr 2024; 12:1302049. [PMID: 38292212 PMCID: PMC10824827 DOI: 10.3389/fped.2024.1302049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Background In refractory respiratory failure (RF), extracorporeal membrane oxygenation (ECMO) is a salvage therapy that seeks to reduce lung injury induced by mechanical ventilation. The parameters of optimal mechanical ventilation in children during ECMO are not known. Pulmonary ventilatory management during this therapy may impact mortality. The objective of this study was to evaluate the association between ventilatory parameters in children during ECMO therapy and in-hospital mortality. Methods A systematic search of PubMed/MEDLINE, Embase, Cochrane, and Google Scholar from January 2013 until May 2022 (PROSPERO 450744), including studies in children with ECMO-supported RF assessing mechanical ventilation parameters, was conducted. Risk of bias was assessed using the Newcastle-Ottawa scale; heterogeneity, with absence <25% and high >75%, was assessed using I2. Sensitivity and subgroup analyses using the Mantel-Haenszel random-effects model were performed to explore the impact of methodological quality on effect size. Results Six studies were included. The median age was 3.4 years (IQR: 3.2-4.2). Survival in the 28-day studies was 69%. Mechanical ventilation parameters associated with higher mortality were a very low tidal volume ventilation (<4 ml/kg; OR: 4.70; 95% CI: 2.91-7.59; p < 0.01; I2: 38%), high plateau pressure (mean Dif: -0.70 95% CI: -0.18, -0.22; p < 0.01), and high driving pressure (mean Dif: -0.96 95% CI: -1.83, -0.09: p = 0.03). The inspired fraction of oxygen (p = 0.09) and end-expiratory pressure (p = 0.69) were not associated with higher mortality. Patients who survived had less multiple organ failure (p < 0.01). Conclusion The mechanical ventilation variables associated with higher mortality in children with ECMO-supported respiratory failure are high plateau pressures, high driving pressure and very low tidal volume ventilation. No association between mortality and other parameters of the mechanical ventilator, such as the inspired fraction of oxygen or end-expiratory pressure, was found. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023450744, PROSPERO 2023 (CRD42023450744).
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Affiliation(s)
- Jaime Fernandez-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Maria Camila Perez
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Juan David Bustos
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Lorena Acevedo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Mauricio Sarta-Mantilla
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Jennifer Guijarro
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Carlos Santacruz
- Department of Anesthesia and Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Daniel Felipe Pardo
- Department of Anesthesia and Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Daniel Castro
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Yinna Villa Rosero
- Department of Critical Care Medicine and Pediatrics, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Hernando Mulett
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
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2
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Zens T, Ochoa B, Eldredge RS, Molitor M. Pediatric venoarterial and venovenous ECMO. Semin Pediatr Surg 2023; 32:151327. [PMID: 37956593 DOI: 10.1016/j.sempedsurg.2023.151327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure. To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology. This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques. Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation. Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.
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Affiliation(s)
- Tiffany Zens
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Brielle Ochoa
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - R Scott Eldredge
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Mark Molitor
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States.
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3
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Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability. Crit Care Clin 2023; 39:255-275. [PMID: 36898772 DOI: 10.1016/j.ccc.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.
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4
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Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2023; 11:197-212. [PMID: 36566767 PMCID: PMC10880453 DOI: 10.1016/s2213-2600(22)00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine, University of Groningen, Groningen, Netherlands.
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mary K Dahmer
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montreal, QC, Canada
| | - Jocelyn Grunwell
- Department of Pediatrics, Division of Critical Care, Emory University, Atlanta, GA, USA
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Bhushan H Katira
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics (Critical Care), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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Kawasaki disease shock syndrome with acute respiratory distress syndrome in a child: a case report and literature review. BMC Pulm Med 2022; 22:220. [PMID: 35668424 PMCID: PMC9168351 DOI: 10.1186/s12890-022-02007-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 05/25/2022] [Indexed: 12/18/2022] Open
Abstract
Background Kawasaki disease (KD) is an acute systemic vasculitis that may involve multiple organs. KD shock syndrome (KDSS) is a rare complication of KD. Pulmonary involvement is rare in KD; reports of patients with KD who develop KDSS and acute respiratory distress syndrome (ARDS) are extremely rare. Case presentation A 2-year-old girl was brought to the emergency department with fever, cough and tachypnea. The patient was diagnosed with KDSS and ARDS. Extracorporeal membrane oxygenation (ECMO) and continuous blood purification were performed because of her critical condition. The patient eventually recovered completely. One year after discharge, there has been no coronary artery dilatation or pulmonary fibrosis. Conclusion KDSS patients may develop ARDS due to fluid resuscitation and the release of inflammatory mediators. Early aggressive management and comprehensive treatment may improve prognosis.
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6
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Kelly DP, Grandin EW, O'Brien KL. How we manage blood product support and coagulation in the adult patient requiring extracorporeal membrane oxygenation. Transfusion 2022; 62:741-750. [PMID: 35170768 DOI: 10.1111/trf.16830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 11/29/2022]
Abstract
Use of extracorporeal membrane oxygenation (ECMO) is increasing among critically ill adults with cardiac and/or respiratory failure. Use of ECMO is associated with hemostatic alterations requiring use of anticoagulation and blood product support. There are limited guidelines to direct transfusion management in the adult patient supported with ECMO. The objective of this article is to describe (1) the role of the transfusion service in providing transfusion support and current understanding of transfusion thresholds, (2) the complexities of monitoring anticoagulation, and (3) the consideration regarding additional factor concentrates and antifibrinolytics within the context of ECMO support. The information provided should assist ECMO care teams in informing transfusion and anticoagulation practice while highlighting key areas for future research and collaboration.
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Affiliation(s)
- Daniel P Kelly
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward Wilson Grandin
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kerry L O'Brien
- Division of Laboratory Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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7
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Zhang Y, Wang C, Wang F, Shi J, Dou J, Shan Y, Sun T, Zhou Y. Lung Ultrasound in Pediatric Acute Respiratory Distress Syndrome Received Extracorporeal Membrane Oxygenation: A Prospective Cohort Study. Front Pediatr 2022; 10:798855. [PMID: 35419318 PMCID: PMC8995848 DOI: 10.3389/fped.2022.798855] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/15/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the prognostic value of the lung ultrasound (LUS) score in patients with pediatric acute respiratory distress syndrome (pARDS) who received extracorporeal membrane oxygenation (ECMO). METHODS A prospective cohort study was conducted in a pediatric intensive care unit (PICU) of a tertiary hospital from January 2016 to June 2021. The severe pARDS patients who received ECMO were enrolled in this study. LUS score was measured at initiation of ECMO (LUS-0 h), then at 24 h (LUS-24 h), 48 h (LUS-48 h), and 72 h (LUS-72 h) during ECMO, and when weaned from ECMO (LUS-wean). The value of LUS scores at the first 3 days of ECMO as a prognostic predictor was analyzed. RESULTS Twenty-nine children with severe pARDS who received ECMO were enrolled with a median age of 26 (IQR 9, 79) months. The median duration of ECMO support was 162 (IQR 86, 273) h and the PICU mortality was 31.0% (9/29). The values of LUS-72 h and LUS-wean were significantly lower in survivors than that in non-survivors (both P < 0.001). Daily fluid balance volume during the first 3 days of ECMO support were strongly correlated with LUS score [1st day: r = 0.460, P = 0.014; 2nd day: r = 0.540, P = 0.003; 3rd day: r = 0.589, P = 0.001]. The AUC of LUS-72 h for predicting PICU mortality in these patients was 1.000, and the cutoff value of LUS-72 h was 24 with a sensitivity of 100.0% and a specificity of 100.0%. Furthermore, patients were stratified in two groups of LUS-72 h ≥ 24 and LUS-72 h < 24. Consistently, PICU mortality, length of PICU stay, ratio of shock, vasoactive index score value, and the need for continuous renal replacement therapy were significantly higher in the group of LUS-72 h ≥ 24 than in the group of LUS-72 h < 24 (all P < 0.05). CONCLUSION Lung ultrasound score is a promising tool for predicting the prognosis in patients with ARDS under ECMO support. Moreover, LUS-72 h ≥ 24 is associated with high risk of PICU mortality in patients with pARDS who received ECMO.
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Affiliation(s)
- Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China.,Clinical Research Unit, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fei Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yijun Shan
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ting Sun
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yiping Zhou
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Cui Y, Zhang Y, Dou J, Shi J, Zhao Z, Zhang Z, Chen Y, Cheng C, Zhu D, Quan X, Zhu X, Huang W. Venovenous vs. Venoarterial Extracorporeal Membrane Oxygenation in Infection-Associated Severe Pediatric Acute Respiratory Distress Syndrome: A Prospective Multicenter Cohort Study. Front Pediatr 2022; 10:832776. [PMID: 35391748 PMCID: PMC8982932 DOI: 10.3389/fped.2022.832776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been increasingly used as rescue therapy for severe pediatric acute respiratory distress syndrome (PARDS) over the past decade. However, a contemporary comparison of venovenous (VV) and venoarterial (VA) ECMO in PARDS has yet to be well described. Therefore, the objective of our study was to assess the difference between VV and VA ECMO in efficacy and safety for infection-associated severe PARDS patients. METHODS This prospective multicenter cohort study included patients with infection-associated severe PARDS who received VV or VA ECMO in pediatric intensive care units (PICUs) of eight university hospitals in China between December 2018 to June 2021. The primary outcome was in-hospital mortality. Secondary outcomes included ECMO weaning rate, duration of ECMO and mechanical ventilation (MV), ECMO-related complications, and hospitalization costs. RESULTS A total of 94 patients with 26 (27.66%) VV ECMO and 68 (72.34%) VA ECMO were enrolled. Compared to the VA ECMO patients, VV ECMO patients displayed a significantly lower in-hospital mortality (50 vs. 26.92%, p = 0.044) and proportion of neurologic complications, shorter duration of ECMO and MV, but the rate of successfully weaned from ECMO, bleeding, bloodstream infection complications and pump failure were similar. By contrast, oxygenator failure was more frequent in patients receiving VV ECMO. No significant intergroup difference was observed for the hospitalization costs. CONCLUSION These positive findings showed the conferred survival advantage and safety of VV ECMO compared with VA ECMO, suggesting that VV ECMO may be an effective initial treatment for patients with infection-associated severe PARDS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Zhe Zhao
- Pediatric Intensive Care Unit, Senior Department of Pediatrics, The Seventh Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Yingfu Chen
- Critical Care Medicine, Children's Hospital Affiliated to Chongqing Medical University, Chongqing, China
| | - Chao Cheng
- Pediatric Intensive Care Unit, Shengjing Hospital Affiliated to China Medical University, Shenyang, China
| | - Desheng Zhu
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, China
| | - Xueli Quan
- Surgical Intensive Care Unit of Henan Children's Hospital, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xuemei Zhu
- Critical Care Medicine, Children's Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenyan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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9
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Zhang Y, Zhou Y, Shi J, Shan Y, Sun T, Wang C, Shao J, Cui Y. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome in children with leukemia/lymphoma: A retrospective case series. Front Pediatr 2022; 10:955317. [PMID: 36160784 PMCID: PMC9493017 DOI: 10.3389/fped.2022.955317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/15/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The cancer patients with severe acute respiratory distress syndrome (ARDS) benefit from extracorporeal membrane oxygenation (ECMO) remains unanswered. We analyzed clinical characteristics and outcomes of pediatric patients with leukemia/lymphoma who developed ARDS and treated with ECMO. METHODS Pediatric leukemia or lymphoma patients with ARDS who underwent ECMO between August 2017 and December 2021 were retrospectively analyzed in a tertiary pediatric intensive care unit (PICU). RESULTS Seven patients with median age 53 (IQR 42-117) months and 4 males were included. Six cases of leukemia [5 of acute lymphocytic leukemia (ALL) and 1 of acute myelogenous leukemia (AML, M5)] and 1 of non-Hodgkin lymphoma with severe ARDS received ECMO on chemotherapy period. The etiology of ARDS is community or chemotherapy-associated bacterial or/and fungal or viral infection. All the patients received chemotherapy in the 2 weeks prior to ECMO and five were neutropenic at initial ECMO. Six cases underwent veno-arterial ECMO (VA ECMO) and 1 for veno-venous ECMO (VV-ECMO). The median duration of ECMO support was 122 (IQR 56-166) hours. Overall, 42.9% (three of seven) survived to hospital discharge and 6 months survival rate was 28.6% (two of seven). Bleeding was the main ECMO-associated complication occurring in 7 patients, followed by nosocomial infection in 4 cases. All the patients required vasopressor support, and 6 received continuous renal replacement therapy (CRRT). CONCLUSION Our experiences suggest that rescue ECMO provides a selective treatment strategy in childhood hematologic malignancies with severe ARDS.
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Affiliation(s)
- Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Pediatric Extracorporeal Life Support Center, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yiping Zhou
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yijun Shan
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Sun
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Pediatric Extracorporeal Life Support Center, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jingbo Shao
- Department of Hematology and Oncology, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Pediatric Extracorporeal Life Support Center, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
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10
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Bateman ST, Johnson AC, Tiber D, Gauguet S, Fortier L, Valentine S. Pediatric ECMO Candidates at Non-ECMO Centers: Transfer, Cannulate, or Treat Locally? Hosp Pediatr 2021; 11:1172-1178. [PMID: 34470788 DOI: 10.1542/hpeds.2020-004929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric inpatient and intensive care specialists working outside of tertiary medical centers confront difficult clinical scenarios related to how best to care for extremely ill children who may or may not benefit from advanced medical technology, and these clinicians are often faced with limited local availability. Extracorporeal membrane oxygenation (ECMO) is a technology that is only available at a subset of tertiary care centers, and the decision to risk the transfer of a child for the potential benefit of ECMO is challenging. This article is aimed at addressing the main factors and ethical principles related to this decision-making: (1) whether ECMO is the standard of care, (2) clinical decision analysis of the risks and benefits, (3) informed consent and education of the parents and/or guardians, and (4) institutional leadership decision-making. A decisional framework is proposed that incorporates a thoughtful shared decision-making algorithm.
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Affiliation(s)
- Scot T Bateman
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Amanda C Johnson
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David Tiber
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Stefanie Gauguet
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Lauren Fortier
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
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11
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Toh TSW, Ong C, Mok YH, Mallory P, Cheifetz IM, Lee JH. Nutrition in Pediatric Extracorporeal Membrane Oxygenation: A Narrative Review. Front Nutr 2021; 8:666464. [PMID: 34409059 PMCID: PMC8365758 DOI: 10.3389/fnut.2021.666464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) support is increasingly utilized in quaternary pediatric intensive care units. Metabolic derangements and altered nutritional requirements are common in critically ill children supported on ECMO. However, there remains no consensus on the optimal approach to the prescription of nutrition in these patients. This narrative review aims to summarize the current medical literature on various aspects of nutrition support in pediatric patients on ECMO. These include: (1) nutritional adequacy, (2) pros and cons of feeding on ECMO, (3) enteral vs. parenteral nutrition, and (4) proposed recommendations and future directions for research in this area.
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Affiliation(s)
- Theresa S W Toh
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Palen Mallory
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ira M Cheifetz
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
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12
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Barbaro RP, Brodie D, MacLaren G. Bridging the Gap Between Intensivists and Primary Care Clinicians in Extracorporeal Membrane Oxygenation for Respiratory Failure in Children: A Review. JAMA Pediatr 2021; 175:510-517. [PMID: 33646287 PMCID: PMC8096690 DOI: 10.1001/jamapediatrics.2020.5921] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Extracorporeal membrane oxygenation (ECMO) is a form of advanced life support that may be used in children with refractory respiratory or cardiac failure. While it is required infrequently, in the US, ECMO is used to support childhood respiratory failure as often as children receive kidney or heart transplants. ECMO is complex, resource intensive, and potentially lifesaving, but it is also associated with risks of short-term complications and long-term adverse effects, most importantly with neurodevelopmental outcomes that are relevant to all pediatric clinicians, even those remote from the child's critical illness. OBSERVATIONS The 2009 influenza A(H1N1) pandemic, along with randomized clinical trials of adult respiratory ECMO support and conventional management, have catalyzed sustained growth in the use of ECMO. The adult trials built on earlier neonatal ECMO randomized clinical trials that demonstrated improved survival in severe perinatal lung disease. For children outside of the neonatal period, there appear to have been no respiratory ECMO clinical trials. Applying evidence from adult respiratory failure or perinatal lung disease to children outside the neonatal period has important potential pitfalls. For these children, the underlying diseases and risks of ECMO are different. Despite these differences, both neonates and older children are at risk of neurologic complications, such as intracranial hemorrhage, ischemic stroke, and seizures, and those complications may contribute to adverse neurodevelopmental outcomes. Without specific screening, subtle neurodevelopmental impairments may be missed, but when they are identified, children have the opportunity to receive therapy to optimize long-term development. CONCLUSIONS AND RELEVANCE All pediatric clinicians should be aware not only of the potential benefits and complications of ECMO but also that survivors need effective screening, support, and follow-up.
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Affiliation(s)
- Ryan P. Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor; Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore,Paediatric Intensive Care Unit, Department of Paediatrics, The Royal Children’s Hospital, University of Melbourne, Australia
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13
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Harischandra T, Withanaarachchi K, Piyasiri B, Wickramasuriya H, Piyasiri G, Firmin R. Successful use of extracorporeal membrane oxygenation in acute respiratory distress syndrome following accidental chlorine gas inhalation at a swimming pool. Perfusion 2020; 35:543-545. [PMID: 32441230 DOI: 10.1177/0267659120922013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
While there is evidence to support the use of extracorporeal membrane oxygenation in acute respiratory distress syndrome due to a variety of causes, its use in chlorine gas-induced acute respiratory distress syndrome has not been described in the English medical literature. We present a young girl who had severe acute respiratory distress syndrome following exposure to chlorine gas during the disinfection process at a swimming pool. She failed conventional management and underwent venovenous extracorporeal membrane oxygenation. Despite multiple infections and a pneumothorax, she eventually recovered. Chlorine gas was the first agent of chemical warfare which caused a massive death toll during the First World War. Even today, the chemical is produced in large quantities and the threat of a large-scale leak is ever-present from industrial accidents or terrorist attacks. The criteria to assess and manage chlorine gas-induced acute respiratory distress syndrome are likely to be the same as for other causes of acute respiratory distress syndrome and extracorporeal membrane oxygenation can be used successfully.
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Affiliation(s)
| | | | - Bhagya Piyasiri
- Microbiology Department, Karapitiya Teaching Hospital, Galle, Sri Lanka
| | | | - Gihan Piyasiri
- Cardiothoracic Unit, Karapitiya Teaching Hospital, Galle, Sri Lanka
| | - Richard Firmin
- Cardiothoracic Unit, Karapitiya Teaching Hospital, Galle, Sri Lanka.,University Hospitals of Leicester, Leicester, UK
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14
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Hong X, Zhao Z, Liu Z, Liu C, Wang J, Quan X, Wu H, Ji Q, Sun J, Cheng D, Feng Z, Shi Y. Venoarterial Extracorporeal Membrane Oxygenation for Severe Neonatal Acute Respiratory Distress Syndrome in a Developing Country. Front Pediatr 2020; 8:227. [PMID: 32548079 PMCID: PMC7270410 DOI: 10.3389/fped.2020.00227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/15/2020] [Indexed: 01/19/2023] Open
Abstract
Objective: Extracorporeal membrane oxygenation (ECMO) has supported oxygen delivery and carbon dioxide removal in neonatal severe respiratory failure for more than 4 decades. The definition and diagnosis of neonatal acute respiratory distress syndrome (ARDS) was made according to the criteria first established by a Montreux Conference in 2017. By far, there has been no ECMO efficiency studies in neonatal ARDS. We aimed to compare the outcomes of neonates with severe ARDS supported with and without ECMO. Design: Retrospective pair-matched study. Setting: In the present retrospective pair-matched study, the outcomes of severe ARDS with ECMO support and without ECMO support were analyzed and compared. Propensity score matching was conducted. The study subjects were selected from a China Neonatal ECMO (CNECMO) study. In total, five hospitals were included in the CNECMO study. The patients were matched with demographic and clinical data. The primary endpoint was in-hospital mortality. Secondary outcomes included ventilator-time, ICU stay, hospitalization costs and cranial MRI results. Patients: 145 neonates with severe ARDS (Oxygenation Index, OI ≥16) from 5 hospitals. Interventions: No interventions. Measurements and Main Results: We collected the data of 145 neonates with severe ARDS (Oxygenation Index, OI≥16) from 5 hospitals. Among them, 42 neonates received venoarterial (VA) ECMO support, and the remaining 103 neonates were treated with conventional mechanical ventilation. The mortality of ECMO-supported neonates was not significantly different compared with the ESLO neonatal respiratory-supported from 2012 to 2018 (23.8 vs. 32.5%, p = 0.230). After matching with the propensity score we got 31 pairs. The ECMO-supported neonates had a lower in-hospital mortality (6 of 31, 19.4%) vs. non ECMO-supported patients (18 of 31, 58.1%) (p = 0.002). Hospitalization costs of survivors in ECMO-supported neonates were significantly higher than that of non-ECMO-supported neonates (p < 0.001). There was no difference of ventilator-times (p = 0.206), ICU stay (p = 0.879) and cranial MRI (p = 0.899) between the survivors of ECMO-supported and non-ECMO-supported neonates with ARDS. Conclusions: By far, there has been no ECMO efficiency studies in neonatal ARDS. This study found that ECMO-support have superior outcomes compared with non-ECMO-support in neonates with severe ARDS.
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Affiliation(s)
- Xiaoyang Hong
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China
| | - Zhe Zhao
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zhenqiu Liu
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Change Liu
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China
| | - Jie Wang
- Surgical Pediatric Intensive Care Unit, Children's Hospital Affiliated of Zhengzhou University, Zhengzhou, China
| | - Xueli Quan
- Surgical Pediatric Intensive Care Unit, Children's Hospital Affiliated of Zhengzhou University, Zhengzhou, China
| | - Hui Wu
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Qiong Ji
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Jianwei Sun
- Department of Neonatology, Henang Provincial People's Hospital, Zhengzhou, China
| | - Donglinag Cheng
- Department of Neonatology, Henang Provincial People's Hospital, Zhengzhou, China
| | - Zhichun Feng
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
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15
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Erickson S. Extra-corporeal membrane oxygenation in paediatric acute respiratory distress syndrome: overrated or underutilized? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:512. [PMID: 31728365 DOI: 10.21037/atm.2019.09.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified form of cardiopulmonary bypass which may provide support for severe cardiorespiratory failure including paediatric acute respiratory distress syndrome (PARDS). While ECMO was initially demonstrated to successfully support neonates with severe respiratory failure, the use of ECMO has expanded rapidly to support both paediatric and adult respiratory failure. Extracorporeal Life Support Organization (ELSO) registry data shows that the use of ECMO for paediatric respiratory failure has expanded rapidly over the past decades with increasing use of venovenous ECMO. Despite the increasing complexity of children supported by ECMO for ARDS, outcomes have remained consistent with survival to hospital discharge greater than 50%. ECMO complications are still common and potentially devastating, especially neurological complications. There is grade 1 evidence to support the use of ECMO in both neonatal and adult respiratory failure but evidence in paediatric respiratory failure is confined to case series and case-control studies. While there are no published guidelines for use of ECMO in PARDS, in particular no clearly defined inclusion and exclusion criteria, current evidence suggests that children with severe ARDS may benefit from ECMO support, with survival to hospital discharge equivalent or better than conventional management in children with severe ARDS.
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Affiliation(s)
- Simon Erickson
- Paediatric Critical Care, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Senior Lecturer, University of Western Australia, Hackett Drive, Nedlands, Western Australia, Australia
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16
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Orloff KE, Turner DA, Rehder KJ. The Current State of Pediatric Acute Respiratory Distress Syndrome. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2019; 32:35-44. [PMID: 31236307 PMCID: PMC6589490 DOI: 10.1089/ped.2019.0999] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/24/2019] [Indexed: 12/16/2022]
Abstract
Pediatric acute respiratory distress syndrome (PARDS) is a significant cause of morbidity and mortality in children. Children with PARDS often require intensive care admission and mechanical ventilation. Unfortunately, beyond lung protective ventilation, there are limited data to support our management strategies in PARDS. The Pediatric Acute Lung Injury Consensus Conference (PALICC) offered a new definition of PARDS in 2015 that has improved our understanding of the true epidemiology and heterogeneity of the disease as well as risk stratification. Further studies will be crucial to determine optimal management for varying disease severity. This review will present the physiologic basis of PARDS, describe the unique pediatric definition and risk stratification, and summarize the current evidence for current standards of care as well as adjunctive therapies.
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Affiliation(s)
- Kirsten E Orloff
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - David A Turner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
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17
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Can We Use "Pretty Big" Data to Settle the Score in Pediatric Extracorporeal Membrane Oxygenation? Crit Care Med 2019; 45:143-145. [PMID: 27984287 DOI: 10.1097/ccm.0000000000002166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Barbaro RP, Xu Y, Borasino S, Truemper EJ, Watson RS, Thiagarajan RR, Wypij D. Does Extracorporeal Membrane Oxygenation Improve Survival in Pediatric Acute Respiratory Failure? Am J Respir Crit Care Med 2018; 197:1177-1186. [PMID: 29373797 PMCID: PMC6019927 DOI: 10.1164/rccm.201709-1893oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/26/2018] [Indexed: 01/19/2023] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) has supported gas exchange in children with severe respiratory failure for more than 40 years, without ECMO efficacy studies. OBJECTIVES To compare the mortality and functional status of children with severe acute respiratory failure supported with and without ECMO. METHODS This cohort study compared ECMO-supported children to pair-matched non-ECMO-supported control subjects with severe acute respiratory distress syndrome (ARDS). Both individual case matching and propensity score matching were used. The study sample was selected from children enrolled in the cluster-randomized RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) clinical trial. Detailed demographic and daily physiologic data were used to match patients. The primary endpoint was in-hospital mortality. Secondary outcomes included hospital-free days, ventilator-free days, and change in functional status at hospital discharge. MEASUREMENTS AND MAIN RESULTS Of 2,449 children in the RESTORE trial, 879 (35.9%) non-ECMO-supported patients with severe ARDS were eligible to match to 61 (2.5%) ECMO-supported children. When individual case matching was used (60 matched pairs), the in-hospital mortality rate at 90 days was 25% (15 of 60) for both the ECMO-supported and non-ECMO-supported children (P > 0.99). With propensity score matching (61 matched pairs), the ECMO-supported in-hospital mortality rate was 15 of 61 (25%), and the non-ECMO-supported hospital mortality rate was 18 of 61 (30%) (P = 0.70). There was no difference between ECMO-supported and non-ECMO-supported patients in any secondary outcomes. CONCLUSIONS In children with severe ARDS, our results do not demonstrate that ECMO-supported children have superior outcomes compared with non-ECMO-supported children. Definitive answers will require a rigorous multisite randomized controlled trial.
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Affiliation(s)
- Ryan P. Barbaro
- Department of Pediatrics and
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Yuejia Xu
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Santiago Borasino
- Department of Pediatrics, University of Alabama, Birmingham, Alabama
| | - Edward J. Truemper
- Department of Pediatrics, Children’s Hospital and Medical Center of Nebraska, Omaha, Nebraska
| | - R. Scott Watson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | | | - David Wypij
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - RESTORE Study Investigators*
- Department of Pediatrics and
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Pediatrics, University of Alabama, Birmingham, Alabama
- Department of Pediatrics, Children’s Hospital and Medical Center of Nebraska, Omaha, Nebraska
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- The Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; and
- Department of Family and Community Health, School of Nursing, and
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Heidemann SM, Nair A, Bulut Y, Sapru A. Pathophysiology and Management of Acute Respiratory Distress Syndrome in Children. Pediatr Clin North Am 2017; 64:1017-1037. [PMID: 28941533 PMCID: PMC9683071 DOI: 10.1016/j.pcl.2017.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome of noncardiogenic pulmonary edema and hypoxia that accompanies up to 30% of deaths in pediatric intensive care units. Pediatric ARDS (PARDS) is diagnosed by the presence of hypoxia, defined by oxygenation index or Pao2/Fio2 ratio cutoffs, and new chest infiltrate occurring within 7 days of a known insult. Hallmarks of ARDS include hypoxemia and decreased lung compliance, increased work of breathing, and impaired gas exchange. Mortality is often accompanied by multiple organ failure. Although many modalities to treat PARDS have been investigated, supportive therapies and lung protective ventilator support remain the mainstay.
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Affiliation(s)
| | - Alison Nair
- Department of Pediatrics, University of California, San Francisco, CA
| | - Yonca Bulut
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, CA
| | - Anil Sapru
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA; Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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20
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Dauger S, Le Bourgeois F, Guichoux J, Brissaud O. [Acute respiratory distress syndrome in childhood: Changing definition and news from the Pediatric Consensus Conference]. Arch Pediatr 2017; 24:492-498. [PMID: 28343880 DOI: 10.1016/j.arcped.2017.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 10/19/2016] [Accepted: 02/14/2017] [Indexed: 12/12/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a rapidly progressive hypoxemic respiratory insufficiency induced by alveolar filling mainly caused by alveolocapillary wall disruption, following direct or indirect pulmonary injury. Much less frequent in children than in adults, pediatric intensivists had long applied adult guidelines to their daily practice. In 2015, experts from the Pediatric Acute Lung Injury Consensus Conference (PALICC) published the first international guidelines specifically dedicated to pediatric ARDS. After a short summary of the history of the ARDS definition since its first report in 1967, we describe the main diagnostic and therapeutic guidelines for PALICC.
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Affiliation(s)
- S Dauger
- Service de réanimation et surveillance continue pédiatriques, pôle de pédiatrie médicale, et Inserm U1141, hôpital universitaire Robert-Debré, Assistance publique-Hôpitaux de Paris et Université Denis-Diderot, Paris VII, 48, boulevard Sérurier, 75019 Paris, France.
| | - F Le Bourgeois
- Service de réanimation et surveillance continue pédiatriques, pôle de pédiatrie médicale, et Inserm U1141, hôpital universitaire Robert-Debré, Assistance publique-Hôpitaux de Paris et Université Denis-Diderot, Paris VII, 48, boulevard Sérurier, 75019 Paris, France
| | - J Guichoux
- Unité de réanimation pédiatrique, hôpital Pellegrin-Enfants, CHU Pellegrin, université Bordeaux II, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - O Brissaud
- Unité de réanimation pédiatrique, hôpital Pellegrin-Enfants, CHU Pellegrin, université Bordeaux II, place Amélie-Raba-Léon, 33076 Bordeaux, France
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21
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22
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González-Pardo OM, Cassalett-Bustillo G, Núñez F. ECMO respiratorio como opción terapéutica en falla respiratoria refractaria en la edad pediátrica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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23
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A Simple and Robust Bedside Model for Mortality Risk in Pediatric Patients With Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2016; 17:907-916. [PMID: 27487912 PMCID: PMC5268071 DOI: 10.1097/pcc.0000000000000865] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite declining mortality, acute respiratory distress syndrome is still involved in up to one third of pediatric intensive care deaths. The recently convened Pediatric Acute Lung Injury Consensus Conference has outlined research priorities for the field, which include the need for accurate bedside risk stratification of patients. We aimed to develop a simple yet robust model of mortality risk among pediatric patients with acute respiratory distress syndrome to facilitate the targeted application of high-risk investigational therapies and stratification for enrollment in clinical trials. DESIGN Prospective, multicenter cohort. SETTING Five academic PICUs. PATIENTS Three hundred eight children greater than 1 month and less than or equal to 18 years old, admitted to the ICU, with bilateral infiltrates on chest radiograph and PaO2/FIO2 ratio less than 300 in the clinical absence of left atrial hypertension. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty clinical variables were recorded in the following six categories: demographics, medical history, oxygenation, ventilation, radiographic imaging, and multiple organ dysfunction. Data were measured 0-24 and 48-72 hours after acute respiratory distress syndrome onset (day 1 and 3) and examined for associations with hospital mortality. Among 308 enrolled patients, mortality was 17%. Children with a history of cancer and/or hematopoietic stem cell transplant had higher mortality (47% vs 11%; p < 0.001). Oxygenation index, the PaO2/FIO2 ratio, extrapulmonary organ dysfunction, Pediatric Risk of Mortality-3, and positive cumulative fluid balance were each associated with mortality. Using two statistical approaches, we found that a parsimonious model of mortality risk using only oxygenation index and cancer/hematopoietic stem cell transplant history performed as well as other more complex models that required additional variables. CONCLUSIONS In the PICU, oxygenation index and cancer/hematopoietic stem cell transplant history can be used on acute respiratory distress syndrome day 1 or day 3 to predict hospital mortality without the need for more complex models. These findings may simplify risk assessment for clinical trials, counseling families, and high-risk interventions such as extracorporeal life support.
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24
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Clinical Pharmacology Studies in Critically Ill Children. Pharm Res 2016; 34:7-24. [PMID: 27585904 DOI: 10.1007/s11095-016-2033-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/25/2016] [Indexed: 12/19/2022]
Abstract
Developmental and physiological changes in children contribute to variation in drug disposition with age. Additionally, critically ill children suffer from various life-threatening conditions that can lead to pathophysiological alterations that further affect pharmacokinetics (PK). Some factors that can alter PK in this patient population include variability in tissue distribution caused by protein binding changes and fluid shifts, altered drug elimination due to organ dysfunction, and use of medical interventions that can affect drug disposition (e.g., extracorporeal membrane oxygenation and continuous renal replacement therapy). Performing clinical studies in critically ill children is challenging because there is large inter-subject variability in the severity and time course of organ dysfunction; some critical illnesses are rare, which can affect subject enrollment; and critically ill children usually have multiple organ failure, necessitating careful selection of a study design. As a result, drug dosing in critically ill children is often based on extrapolations from adults or non-critically ill children. Dedicated clinical studies in critically ill children are urgently needed to identify optimal dosing of drugs in this vulnerable population. This review will summarize the effect of critical illness on pediatric PK, the challenges associated with performing studies in this vulnerable subpopulation, and the clinical PK studies performed to date for commonly used drugs.
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25
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Nye S, Whitley RJ, Kong M. Viral Infection in the Development and Progression of Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:128. [PMID: 27933286 PMCID: PMC5121220 DOI: 10.3389/fped.2016.00128] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/11/2016] [Indexed: 12/21/2022] Open
Abstract
Viral infections are an important cause of pediatric acute respiratory distress syndrome (ARDS). Numerous viruses, including respiratory syncytial virus (RSV) and influenza A (H1N1) virus, have been implicated in the progression of pneumonia to ARDS; yet the incidence of progression is unknown. Despite acute and chronic morbidity associated with respiratory viral infections, particularly in "at risk" populations, treatment options are limited. Thus, with few exceptions, care is symptomatic. In addition, mortality rates for viral-related ARDS have yet to be determined. This review outlines what is known about ARDS secondary to viral infections including the epidemiology, the pathophysiology, and diagnosis. In addition, emerging treatment options to prevent infection, and to decrease disease burden will be outlined. We focused on RSV and influenza A (H1N1) viral-induced ARDS, as these are the most common viruses leading to pediatric ARDS, and have specific prophylactic and definitive treatment options.
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Affiliation(s)
- Steven Nye
- The University of Alabama at Birmingham , Birmingham, AL , USA
| | | | - Michele Kong
- The University of Alabama at Birmingham , Birmingham, AL , USA
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26
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Choi SH, Yoon SH, Sol IS, Kim MJ, Kim YH, Shin HJ, Kim KW, Sohn MH, Kim KE. Life-threatening human metapneumovirus pneumonia requiring extracorporeal membrane oxygenation in a 26-month-old child. ALLERGY ASTHMA & RESPIRATORY DISEASE 2015. [DOI: 10.4168/aard.2015.3.6.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Sun Ha Choi
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Seo Hee Yoon
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - In Suk Sol
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Hee Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Hong Ju Shin
- Division of Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Earn Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
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